SAVING

LIVES
CHANGING
LIVES
INTEGRATED “SMART” STUDY
District Umerkot
Sindh, Pakistan
November-2018
 TABLE OF CONTENT

Contents
Acronyms.................................................................................................................................... 3

List of Tables ............................................................................................................................... 4

List of Figures .............................................................................................................................. 5

Acknowledgements .................................................................................................................... 6

Executive Summary .................................................................................................................... 7

Introduction.............................................................................................................................. 10

District Profile ........................................................................................................................... 10

Figure 2: District Map................................................................................................................ 12

Survey Objectives ..................................................................................................................... 12

Specific objectives..................................................................................................................... 12

Methodology ............................................................................................................................ 13

Meetings conducted with provincial and district authorities .................................................... 16

Training and Organization of Survey Team ............................................................................... 16

Ethical Consideration ................................................................................................................ 17

Data Quality Assurance Process ................................................................................................ 18

Data collection .......................................................................................................................... 18

Household questionnaires: ....................................................................................................... 19

Data entry and analysis:............................................................................................................ 19

Results and Findings: ................................................................................................................ 20

Anthropometric Measurements (Based on WHO Standards 2006)........................................... 20

Historical Trend of Malnutrition ............................................................................................... 28

Maternal Nutritional Status ...................................................................................................... 29

Nutrition Programme Coverage ................................................................................................ 29

Infant and Young Child Feeding Practices (IYCF) Children 0-23 months..................................... 30

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Minimum Dietary Diversity (MDD) ........................................................................................... 31

Household Food Security Circumstance .................................................................................... 31

Household Coping Strategy....................................................................................................... 32

Household Dietary Diversity (HDDS) ......................................................................................... 33

Child Morbidity ......................................................................................................................... 33

Mortality................................................................................................................................... 34

Vaccination and Vitamin-A Coverage........................................................................................ 35

Water, Sanitation and Hygiene (WASH).................................................................................... 35

Conclusion ................................................................................................................................ 37

Recommendations:................................................................................................................... 38

Annexure: I Plausibility Check ..................................................................................................... 0

Annexure: II List of Surved Clusters ............................................................................................. 0

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Acronyms
ARI Acute Respiratory Infection
BCG Bacillus Calmette Guerin
CI Confidence Interval
CMAM Community Based Management of Acute Malnutrition
CMR Crude Mortality Rate
DOH Department of Health
ECHO European Civil Protection and Humanitarian Aid Operations
ENA Emergency Nutrition Assessment
EPI Expended Programme for Immunization
FSL Food Security and Livelihood
GAM Global Acute Malnutrition
HH Household
HDDS Household Dietary Diversity
IYCF Infant and Young Child Nutrition
HAZ Height-for-Age z-score
LHW Lady Health Worker
MAM Moderate Acute Malnutrition
MDD Minimum Dietary Diversity
MICS Multiple Indicator Cluster Survey
MUAC Mid Upper Arm Circumference
NGO Non-Government Organization
NOC No Objection Certificate
NSP Nutrition Support Program
OTP Outpatient Therapeutic Programme
PPS Probability Proportion to Size
PLW Pregnant and Lactating Women
RC Reserved Cluster
RNT Random Number Table
RTK Rapid Test Kit
SAM Severe Acute Malnutrition
SI Sampling Interval
SMART Standardized Monitoring and Assessment of Relief and Transition
TSFP Targeted Supplementary Feeding Programme
UC Union Council
U5MR Under Five Mortality Rate
WASH Water, Sanitation and Hygiene
WAZ Weight-for-Age z-score
WFP World Food Programme
WHZ Weight-for-Height z-score
WHO World Health Organization

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List of Tables

Table: 1 Summary of Acute & Chronic Malnutrition Trends …………………………………………………..…… 7

Table: 2 History of WFP Programmes in Umerkot ………………………………………………………….………….10
Table 3 Sample Size for Anthropometry …………………………………………………………….…………….….. 14
Table: 4 Sample Size for Retrospective Mortality ……………………………………………….…………..………… 14
Table: 5 Distribution of Age and Sex of Sample ……………………………………………………………………… 19
Table: 6 Prevalance of Acute Malnutrition based on Weight-for-Height Z-Score and Sex …....20
Table: 7 Prevalence of GAM based on MUAC and Gender …………………..…………………………..……22
Table: 8 Prevalence of Acute Malnutrition by Age based on MUAC ……………………………….………23
Table: 9 Prevalence of stunting based on height-for-age z-scores and by Gender ……..…………24
Table: 10 Prevalence of stunting by age based on height-for-age z-scores ………………..……………24
Table: 11 Prevalence of Underweight based on Weight-for-Age Z-Score and by Gender …….……25
Table: 12 Prevalence of Underweight by Age based on Weight-for-Age Z-Score ……………………26
Table: 13 Prevalence of Acute Malnutrition in PLW ………………………………………………………..…….…27
Table: 14 CMR &U5MR …………………………………………………………………………………………………………..…33
Table: 15 Vaccination (BCG, Measles) and Vitamin-A coverage ……………………………………....…..…33

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List of Figures
Figure: 1 District Facts ……………………………………………………………………………………………………………9
Figure: 2 District Map …………………………………………………………………………………………………………… 11
Figure: 3 Survey Teams Composition ……………………………………………………………….…………………….16
Figure: 4 Distribution of Sex by age group …………………………………….………………………………………. 20
Figure: 5 Prevalence of Acute Malnutrition by Age based on WHZ-Score ………….…………………… 21
Figure: 6 WHZ-Score Distribution ………………………………………………………………….……………….……. 21
Figure: 7 Cumulative Distribution of WHZ (Overall and gender) …………………………………..…………22
Figure: 8 Cumulative distribution of stunting (Overall and Gender) based on MUAC …………...…23
Figure: 9 HAZ-Score Distribution ……………………………………………………………………………...………….. 24
Figure: 10 Cumulative Distribution HAZ (Overall and gender) ……………….………………………………… 25
Figure: 11 WAZ-Score Distribution ……………………………………………………….………….……………………. 26
Figure: 12 Cumulative Distribution of WAZ (Overall and Gender) …………………………………………….26
Figure: 13 Historical Trend of Malnutrition in District Umerkot ………………………..………………………27
Figure: 14 Programme Covarage (Children OTP& TSFP and TSFP PLW) ……………………….…………..28
Figure: 15 IYCF Pratices …………………………………………………………………………………………..………………29
Figure: 16 Minimum Dietary Diversity for children age 06-23 months ……………………..………………29
Figure: 17 Source of income/livelihood …………………………………………………………….…………………… 30
Figure: 18 Household Dietary Diversity Score (HDDS) ………………………………………..………………….. 31
Figure: 19 Trends of Child morbidity and Health Services Seeking Behaviours …………………..…….32
Figure: 20 Health Services Seeking Behaviours …………………………………………………..…………………..32
Figure: 21 Water sources for drinking and personal hygiene …………………………..………………………34

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Acknowledgements
World Food Programme (WFP), Pakistan hereby acknowledges the lead role of Provincial and
District health authorities for timely conduct of the “Integrated SMART” Study in District Umerkot-
Sindh. WFP in particular appreciates the timely approval initiatives of the “Director General Health
Services-Sindh” for facilitating the smooth access to district Umerkot. The active participation of
the District health authorities and Nutrition Support Programme significantly contributed to
ensure the quality of trainings, standardization tests, field level data collection and regular field
level monitoring of the assessment exercise.

WFP also extends it heartily and sincere gratitude to all the direct and indirect participants of the
survey, predominantly for the valuable feedback from the mothers and community elders who
actively volunteered for the successful conduct of the study. The assessment team also appreciates
the contribution of Shifa Foundation for providing a very competent field teams for the devoted
hard work and keen interest in collecting quality data for the study.

WFP further concedes the generous support of “European Civil Protection and Humanitarian Aid
Operations” (ECHO) for timely conduct of the study through availability of the required financial
resources.

Lastly, the assessment team hereby, expresses its thankfulness to the Department of Health,
Nutrition Support Programme, ECHO and the respective communities for the valuable support,
which would for sure contribute to understand and support the nutritional needs of Children and
mothers in district Umerkot.

Technical Advisor: Ms. Cecilia GARZON (WFP-ISB)

Technical Lead/s: Dr Ijaz Habib & Fazal Dad (WFP)

Monitoring and Supervision Support: Dr. Mehboob Ahmed Samejo (DNO), NSP-Umerkot
Dr Jawaid Ahmed Bhutto, Dept. Director GHS-Sindh
Dr Yasir Ihtesham (WFP, ISB)
Provincial operational lead/s: Ms. Salma Yaqub, Sabira Soomro, Jalil Ahmed (WFP)

Filed Teams (Enumerators) support: Shifa Foundation

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Executive Summary
Being part of Southern Sindh, district Umerkot is historically prone to moderate droughts and
categorized as highly vulnerable based on the Drought Vulnerability Index1. Over the past decades,
multiple years have been signified as severe drought years (1969, 1974, 1987, 2002), with the most
recent droughts occurring in 2013-15. On September 05, 2018, the Sindh government declared
large parts of six the districts2, including Umerkot, as ‘calamity-affected areas’ due to low rainfall
in the outgoing monsoon season. The impact of subsequent years of vulnerabilities in Umerkot is
evident in the series of nutritional assessments conducted by government through technical
assistance of various partners. The MICS 2014 and SMART studies in 2016 and 2017 document
alarmingly high trends of acute and chronic malnutrition in district Umerkot, all exceeding World
Health Organizations standard critical emergency thresholds.

In response to the Sindh government’s September 2018 notification of calamity-affected areas, as

well as to examine the unusual acute malnutrition trends reported in the preliminary draft of the
“Sindh Drought Needs Assessment Report, November 2018”, WFP in consultation with the
provincial health department commissioned an in-depth nutrition assessment of the situation
through a “Standardized Monitoring and Assessment of Relief and Transitions” (SMART) study in
all union councils of district Umerkot.

The Integrated SMART assessment data collection was initiated on November 18 and concluded
on November 23rd, 2018, with an overall sample of 470 children 6-59 months of age, against a
total planned 431 children (6-59 months) from 470 households and 142 pregnant and lactating
women (PLW) assessed for malnutrition through anthropometric measurements.

1
https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/assessments/sindh_dro
ught_needs_assessment-preliminary_findings.pdf
2
Tharparkar, Umerkot, Thatta, Dadu, Sanghar and Kambar Shahdadkot

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The summary of findings relating to acute and chronic malnutrition is illustrated in Table 1:
Table1: Summary of Acute & Chronic Malnutrition Trends
(Wasting, Stunting & Under Weight)
Indicators All (n = 470) Boys (n = 250) Girls (n = 220)
Prevalence of global
acute malnutrition (115) 24.5 % (67) 26.8 % (48) 21.8 %
based on WHZ (20.5 - 28.9 95% (20.8 - 33.7 95% (16.2 - 28.8
(<-2 z-score and/or C.I.) C.I.) 95% C.I.)
oedema)
Prevalence of global
acute malnutrition (66) 14.0 % (25) 10.0 % (41) 18.6 %
WHO
based on MUAC (11.1 - 17.6 95% (6.3 - 15.4 95% (14.0 - 24.3
2006
(< 125 mm and/or C.I.) C.I.) 95% C.I.)
oedema)
Prevalence of Stunting (254) 54.0 % (138) 55.2 % (116) 52.7 %
based on HAZ (<-2 z- (49.1 - 58.9 95% (48.4 - 61.8 95% (46.6 - 58.7
score) C.I.) C.I.) 95% C.I.)
Prevalence of (261) 55.5 % (140) 56.0 % (121) 55.0 %
underweight based on (49.7 - 61.2 95% (48.7 - 63.1 95% (47.3 - 62.5
WAZ (<-2 z-score) C.I.) C.I.) 95% C.I.)

The assessment results revealed alarmingly high levels of acute and chronic malnutrition across all
union councils of district Umerkot, with no significant variance of trends between urban and rural
population3. The prevalence of acute malnutrition based on weight-for-height was 24.5 % (SAM
7.2 % & MAM 17.2 %), while the MUAC based assessment revealed a 14.0 % prevalence rate of
acute malnutrition with comparatively higher trends in girls (18.6%) as compared to boys (10.0%).
Based on height–for-age, the prevalence of stunting was 54%, this means that more than half of
the children under five are below their average heights, exceeding the WHO critical threshold level
(≥ 40%). The prevalence of underweight based on weight-for- age z-score, the indicator of chronic
malnutrition, was 55.5 %. Similarly, in PLW, 15% were found to be malnourished based on the
MUAC criteria, with only 27% taking iron/folic acid supplementation. The overall nutrition
programme coverage for children 06-59 months was recorded as 11% (OTP: 6% and TSFP: 12%).

A total of 189 mothers with children aged 0-23months were assessed for infant and young
child feeding practices (IYCF). Of the mothers’ interviewed, 41% reported early initiation of
breastfeeding within one hour of the child’s birth. However, only 26% of mothers reported
exclusively breastfeeding for the first 6 months. Continued breastfeeding for one year was

3
Urban: 23.9% GAM, Rural: 24.5% GAM

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reported by 81% mothers. Only 23% of children (6-23 months) were reported to have initiated
complementary feeding at the age of 6 months. In terms of dietary frequency, 10% of
mothers reported feeding their children 1-3 times per day, while 69% reported feeding more
than 3 times per day. A total of 47% mothers reported that they had participated in an
awareness session on IYCF delivered by the lady health workers or NGOs workers in the area.
The overall minimum dietary diversity score for children 6-23 months of age was found to be
very low – i.e. 08, which indicates very poor dietary diversity. The overall household dietary
diversity score (HDDS) was 4.7, which indicates that each of the assessed household
consumed only 4.7 out of the 12 food groups at household level. This finding demonstrates
poor access to diverse foods in the area. Additionally, 69% households were confirmed as
using iodized salt through an on-spot analysis using the Rapid Test Kits.

Children aged 6-59 months suffered from diarrhoea, fever and acute respiratory infections (ARI) in
the two-weeks preceding the survey. Access to health centers was a challenge for participating
households. The BCG and measles coverage was not significant except in the case of vitamin A.
Under five morbidity data reflected 16% and 7% prevalence of diarrheal diseases and acute
respiratory infections, respectively. The Expanded Programme on Immunization (EPI) coverage
was reported at 78% for BCG (scar-based), 34% for measles (card-based) and 58% for measles
(mother recall-based), while vitamin A coverage was estimated at 91% (mother recall-based). The
crude mortality rate was reported as 0.08/10,000 per day and under five mortality rate was
recorded as 0.44 /10,000 per day during the recall period, both indicators fall below the WHO4
emergency threshold, which could be correlated with the comparatively less harsh
seasonality factors during the survey period.

The WASH situation presents slight contrast between Eastern and Western regions of
Umerkot, with water scarcity prevailing in the east and salinity challenges in the west. Of the
households interviewed, 48% relied on hand pumps,19% relied on a piped supply, 15%
fetched water from protected wells and another 10% collected water from public tap stands.
A total of 53% of the respondents believed their water source is safe for drinking, while 31%
used cloth to filter water before drinking and only 2% boiled water before drinking. Fifty
percent of respondents revealed washing hands before meals and after using the latrine.

4 Crude mortality rate (CMR) is 1 per 10 000 per day and 2 per 10 000 per day for under-five mortality rate (U5MR).

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Based on observations, 76% of the household had soap or detergent for handwashing.
However, only 23% of the household’s had flush latrines, while 62% practiced open defecation
in the bushes.

Introduction
Background and Rational for the Survey
World Food Programme (WFP) in collaboration with the Sindh Government, Department of Health
(Nutrition Support Programme, NSP) and in partnership with Concern World-Wide has responded
to the emergency nutrition situation in Sindh through the “CMAM Surge” approach with the
funding support of “European Civil Protection and Humanitarian Aid Operations” (ECHO). The
CMAM surge approach aims at outlining a process and set of practical tools to capacitate the
government district health authorities to determine the seasonal malnutrition caseload surges
that are likely to occur and to better prepare for a timely and effective response without reliance
on external technical assistance. The current surge pilot based approach is focusing on the most
vulnerable areas of Sindh, where frequent environmental shocks are common, resulting in
increased need and demand for assistance. By building the capacity of the government to deal
with the surges during shocks and emergencies will enable the system to better cater for the needs
of acutely malnourished children under five and pregnant and lactating women (PLW).
The SMART survey was used as a capacity building tool for district and provincial government
health authorities to periodically assess the malnutrition status of the population, particularly in
the food insecure areas such as Umerkot district. The study also contributes to the periodically
assessment of food insecurity, livelihoods, WASH, mortality and morbidities indicators and help
design the nutrition specific and sensitive interventions based on the available resources.

District Profile
District Umerkot is geographically located in the south-
Figure 1: District Facts
east corner of Sindh, with the current administrative
Population: 1,073,146
setup, designated in December 2004 after separation Total Area: 5,608 km2
from District Mirpurkhas. The Eastern part of the district No of Talukas: 04
No of Union Councils: 50
is bordered by the Thar Desert. The area is rain-fed with
Literacy rate: 40% (20% female)
limited irrigation possibilities. The Western portion of the No of Health Facilities: 127
district comprises of an irrigated green belt and covers Major Livelihood Sources:
Agriculture and Livestock’s

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three talukas of Pithoro, Sumaro, Kunri and some parts of Umerkot.

Administration: The district has its headquarters in Umerkot City and is segregated into four
Talukas, (Umerkot, Samaro, Kunri, Pithoro), 50 Union Councils and 235 mouzas.

Livelihoods: As Umerkot is primarily a rural district, agriculture forms a major component of its
livelihood. The major crops grown are cotton, wheat, sugarcane and chili, whereas crops such as
bajra (millet) and jawar (maize) are sown in the arid belt. Livestock is a key secondary source of
livelihood for those in the irrigated areas and forms a primary source of livelihood for those in the
arid areas. However, as a result of the prolonged drought the emphasis on livestock in the Thar
region is seen to be declining with people turning towards unskilled wage labor.

Nutrition and Health services: The

district has 127 health facilities Table 2

available and an estimated 546,127

individuals are covered by a network
of 542 LHWs. The district also has
access to a functioning Nutrition
Stabilization Centre.

Disaster Profile: Umerkot district is susceptible to two major disasters. In the irrigated area,
riverine flooding has proven to be a major concern. In the 2011 floods, an estimated 350,258
people were affected, with 32,164 houses and 98% of the total cropping area was damaged in
Umerkot. The part of the district that is covered by the Thar Desert is severely drought prone.
Starting in 2013, due to shortage of rainfall, the area has been immersed in one of the worst
droughts to hit the area. As a result of this drought, 225,389 people were estimated to have been
affected (the total population residing in the drought affected UCs). The greatest impacts of the
drought are on the availability of fodder for livestock causing an increase in diseases and death in
livestock’s in the area. The shortage of rainfall has also had major impacts on crop cultivation as
all agriculture activities are sustained through rainfall in the area. The drought like condition usually
disturbs the income generation/livelihood pattern of the community, and in return the affected
community usually either migrate to neighboring areas for search for labor or start selling out their
assets i.e. livestock as a coping strategy to overcome the food insecurity situation.

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Figure 2: District Map

Survey Objectives
The overall purpose of the SMART survey was to measure the nutritional status of children aged
6-59 months and PLW as well as the crude death rate and under 05 mortality rates in Umerkot
district of Sindh province, Pakistan.

Specific objectives
a) To determine the prevalence of acute and chronic malnutrition (GAM and SAM) among
children aged 6 to 59 months of age
b) To assess the crude death rate (CDR) and under five mortality rates (U5MR)
c) To assess the recent morbidity status among children 6- 59 months

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 d) To assess the basic immunization coverage for “BCG and measles” and “Vitamin A”
Supplementation among children 6-59 months
e) To estimate the prevalence of malnutrition among pregnant and lactating women (PLWs)
using Mid-Upper Arm Circumference (MUAC)
f) To assess the infant and young child feeding practices
g) To determine the “Food security and Livelihoods” situation in district Umerkot
h) To study the population’s access to and utilization of safe water, sanitation and hygiene
practices;
i) To recommend appropriate actions and way forward for the assessed geographic area.

Methodology
Survey Type and Area
The cross-sectional population survey was conducted in 48 out of 505 union councils of District
Umerkot6. The survey design entailed quantitative and qualitative methods to collect the
desired information under specific objectives.

Survey Period
The survey process started on 14th November and successfully concluded on 24th November,
2018 (inclusive of 04 days’ enumerators training, standardization and field testing).

Survey Design
The cross-sectional survey used a two-stage cluster sampling technique, adopted from the SMART
methodology focusing on standard nutrition, food security, WASH7 and IYCF8 indicators.
Anthropometric and other data sets on the indicators were gathered simultaneously. Data from
the government of Sindh was used as a source of population data. The sample size were calculated
using the ENA9 for SMART software ( version 2015).
The clusters were defined as villages and were considered as the smallest geographical unit.
Random number table was used in the second stage on clusters level to ensure probability
sampling in each cluster using probability proportional to size (PPS10) method. Both quantitative

5
Security access limited to two Union Councils (Chhor & Khokhrapar)
6 For this survey, the new number/administrative bounders of Talukas and UCs have been used, received from the govt.
7 Water, Sanitation and Hygiene
8 Infant and Young Child Feeding
9 Emergency Nutrition Assessment
10 Probability proportion to size

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and qualitative data was collected from randomly selected households by adapting the standard
SMART questionnaire templates as per targeted indicators.

Survey Population
- Children aged 06-59 months and PLW: Anthropometric measurements of children age
06-59 months using weight, height, MUAC and oedema were carried out and for PLW
nutritional status were assisted using MUAC measurement.
- Mothers of children under two years of age: Assessing the infant and young child
feeding practices, relevant information were gathered from mothers with children who
were under two years of age via household questionnaires in all selected villages.
- Households: To assess the FSL and WASH situation, mortality and morbidity rates, the
relevant information was collected from randomly selected households.

Sample Size Calculation

As the survey was a combination of anthropometry and mortality assessment, the sample size was
thereafter determined separately based on the parameters of estimated prevalence rates of
malnutrition11 (GAM), desired precision and design effect using the Emergency Nutrition
Assessment (ENA) for SMART software ( version 2015) as shown in Table 3.
Table 3: Sample Size for Anthropometry
Estimated GAM

Design effect

Estimated HH Clusters
Percent Percent of
Precision

sample Average Sample (13 HH

District <5 Non-
size HH size Size per
children respondent
children require cluster)

Umerkot 22% 5 1.4 431 15 7 3 470 36

Sample size for the retrospective mortality was determined based on the parameters including
estimated crude death rate, desired precision, design effect, recall period, non-respondent and
average household size as shown in Table 4.

Table 4: Sample Size for Retrospective Mortality

11 Multiple Indicators Cluster Survey-2014 Sindh

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 Population to
Design effect
HH

be included
Death rate
Estimated
Percent Percent of

Precision
Average Sample Recall
District <5 Non-
HH size Size Period
children respondent
require

Umerkot 2/10,000 0.3 1.5 1452 15 7 3 216 95

Sampling
Two stage cluster sampling technique was used for sampling, the stage-1 sampling involved the
selection of clusters (villages) from District Umerkot followed by sampling of households in the
clusters to be surveyed in stage-2.

Stage-1: Random Selection of Clusters

The survey area was divided into small geographical units (villages) and considered as clusters. List
of clusters from 43 UCs of all four talukas (Umerkot, Kunri, Samaro and Pithoro) of district Umerkot
with their estimated total population were obtained. Clusters were assigned using the ENA for
SMART software which using the PPS methodology and randomly selected 36 clusters along with
4 Reserved Clusters (RC). Two union councils (Khokrapar and Chore) were excluded from the
cluster list at first stage sampling due to security issues.

Stage-2: Simple random or Systematic Random Selection of Households

- Simple random sampling: Two options were adopted i.e. When it was possible to make
a list of all the households in the village, a list was made, from which, households were
randomly selected by using random number table. But if creating a list of households in
the village was not possible, then the households were selected based on systematic
random sampling.

- Systematic selection of households: Households to be surveyed were selected during

the second stage sampling by the survey field team. Upon arrival to the identified cluster,
they confirmed the number of households in the area and listed all the households.
Systematic sampling technique was applied for calculating the appropriate sampling
interval (SI). First household was selected using a random number table (RNT) followed by
the PPS method for selection of the remaining households. A total of 13 households were

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 selected per cluster. The selected households were interviewed regardless of the presence
of children age 06-59 months. All the households were interviewed for FSL, WASH and
mortality, while households with children aged 06-59 months were assessed for
anthropometric measurements.
- Segmentation Technique: In clusters with heavy population density (having more than a
100 households), the standard procedure was applied before systematic sampling using
SMART methodology. The whole clusters were split into equal or unequal segments (sub
units/merging) on the basis of natural barriers and public points according to the cluster
geographical conditions. Once the segments were divided, then one segment randomly
selected for conducting the survey.

Meetings conducted with provincial and district authorities

Before proceeding with the survey, WFP team met with the relevant provincial and district health
authorities for reaching consensus on the survey objectives, background analysis, rational,
methodology, key logistics and partnership arrangements for roles and responsibilities at different
stages of the survey. The district level access for data collection was formally agreed upon through
issuance of a No-Objection certificate (NOC) from the Director General Health Services. The
provincial and district health representatives actively participated in the planning phase, training
of enumerators, the standardization tests, field testing and day-to-day monitoring of the data
collection process in the field.

Training and Organization of Survey Team

WFP contracted the services of Shifa Foundation (a national NGO) as a third party for hiring of the
enumerators, with priority recruitment of enumerators with hands-on skills and previous
experience in nutrition surveys and nutrition background. The survey teams were provided 4 days
of extensive training (14th to 17th Nov-2018). The training focused on survey objectives, sampling
procedures, anthropometric measurements, questionnaires administration and communication
skills with the respondents. Both the standardization test and pilot field testing were carried out
during the training. The survey team conducted the standardization test, with 10 children under
five years of age accompanied by their caretakers. Each enumerator measured the MUAC, weight,
height/length of each respective child at least two times. The Director Health Services and District
Health Officer also participated in the exercise. The purpose of the test was to check the

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enumerators competency on precision and accuracy with reference measurements. The data was
analyzed using the ENA software.
Data collectors were divided into six teams composed of two female enumerators and one male
team leader per team. The team leaders were representative of the team for coordination with
community elders and further arrangements. The focal persons from the Provincial and District
Health Departments observed the training sessions, standardization, field testing and jointly
monitored the field level data collection processes with WFP team. The plausibility score reflected
high levels of consistency and precision across all enumerators. Enumerators with excellent
precision results were assigned to take anthropometric measurements during the data collection
process. Each team’s work plan was prepared in a pre-made template indicating team members’
names, the area in which they were to collect data and the dates for data collection. Each team
was tasked with covering one cluster per day, hence 36 clusters completed in 6 days. The work
plans provided to each team helped in monitoring fieldwork. Teams were given guidance each day
before leaving for the field and supported at the field level.

Figure 3: Survey Teams Composition

Ethical Consideration
Verbal informed consent regarding the survey was sought from community gatekeepers in each
village. Verbal informed consent was also sought from the caretakers of the children and from the
head of the households before proceeding with the household’s level data collection. The
identities of the participants were kept confidential and the decision of any individual or household
to not participate in the survey was respected.

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Data Quality Assurance Process
Several steps were taken to ensure data quality during all survey processes right from the start of
planning phase till the final stage of data entry and analysis, which ensured the data quality with
an excellent plausibility score of 4 %. These steps include:
- Translation of questionnaires into the local language and reverse translation for recording
the actual responses,
- A pilot test in a nearby non-clustered village with participation of all 06 teams, government
and WFP CO and PO teams,
- Revision of the questionnaires based on discussions during training exercise and pilot field
testing as per local context,
- Use of local event calendar for estimating the ages of children, the event calendar was used
in instances where the caretakers had no document to verify the ages of targeted children,
- WFP and Government team’s monitoring and supervisory presence with each team in
field, including daily calibration of anthropometric tools for ensuring precision,
- End of the day de-briefing sessions with each team with triangulation of information in line
with preceding day’s data analysis of unusual trends through plausibility checks,
- Daily data entry and analysis for observed trends by WFP technical teams.

Data collection
The actual data collection was undertaken over a 6-day period (18th to 23rd Nov-2018). During this
period, anthropometric and household data was gathered as explained below:
• Anthropometric data: Anthropometric data was collected from all eligible children aged
06-59 month. A structured questionnaire was used to gather this information. The data
gathered included:
o Age: The children immunization card or birth certificate was the primary
source for this information however, in the absence of these documents, local
event calendar was used to estimate the age of children
o Sex: This is recorded as either F for female and M for male
o Weight: Uni-scale was used to measure the weight of eligible children. In order
to enhance the quality of data and accuracy, all scales were calibrated using a
standard weight before taking any measurement. The weights are recorded to
the nearest 0.1 kg.

Page 18 of 43
 o Height/ length: Recumbent length was taken for children less than 85 cm or
less than 2 years of age while those greater or equal to 85 cm or more than 2
years of age were measured standing up using 130 cm long height board
o MUAC: Mid Upper Arm Circumference (MUAC) was measured using a three-
color coded (red, yellow and green), flexible, non-elastic 26.5 cm long tape.
The measurements were on the left arm to the nearest cm.
o Bilateral oedema: This was assessed by the application of moderate thumb
pressure for at least 3 second to both feet for recording the nutritional
oedema.

• Household questionnaires: A brief household questionnaire was used for collecting

information covering children vaccination, mortality, morbidity, IYCF practices of
children 0-23 months and household FSL & WASH situations.

Data entry and analysis:

Daily data entry was undertaken for anthropometric and mortality data to ensure close
supervision and quality of data. The data eventually analysed using the ENA software. The
household questionnaire data sets were entered and analysed using Microsoft excel.

Page 19 of 43
Results and Findings:
Anthropometric Measurements (Based on WHO Standards 2006)
Distribution of Children by Age and Sex:
Children aged 06-59 months were assessed during this study, the below table elaborates the
distribution of these children by different age groups indicating that 53.2% and 46.8% of these
children were boys and girls, respectively. The overall boy, girl ratio is 1.1, which falls under
the recommended range of 0.8-1.212 demonstrating receptiveness in sample selection.
However, this is not the case with children 18-28 months and 30-41 months, the ratio exceeds
the 1.2 upper limit, the deviation may be a result of using a local event calendar for
approximating the ages of children where age verification documents such birth certificates
and EPI cards were not available. The sex value revealed that the boys and girls were equally
represented in the survey as indicated in Table 5.

Table 5: Distribution of Age and Sex of Sample

Boys Girls Total Ratio
Age (Month) no. % no. % no. % Boy: girl
6-17 50 47.2 56 52.8 106 22.6 0.9
18-29 64 61 41 39 105 22.3 1.6
30-41 62 54.4 52 45.6 114 24.3 1.2
42-53 56 52.3 51 47.7 107 22.8 1.1
54-59 18 47.4 20 52.6 38 8.1 0.9
Total 250 53.2 220 46.8 470 100 1.1

12 WHO (2000). The Management of Nutrition in Major Emergencies

Page 20 of 43
Figure 4: Distribution of Sex by age group

Boys % Girls %

54-59 47.4 52.6

42-53 52.3 47.7

30-41 54.4 45.6

18-29 61 39

6-17. 47.2 52.8

Acute Malnutrition based on Weight-for-Height Z-Sores and by Sex

Acute malnutrition refers to low weight-for-height with or without the presence of a bilateral
pitting oedema. Using the WHO 2006 reference standards for weight-for-height z-scores
(WHZ), the prevalence of Global Acute Malnutrition (GAM) was 24.5 % (95% CI 20.5 - 28.9),
with severe acute malnutrition (SAM) reported as 7.2% (95% CI 13.9 - 21.2) and moderate
acute malnutrition (MAM) as 17.2 % (95% CI 5.1 - 10.3).These findings illustrate the critical13
nutrition situation present in the district.
According to the MICS 2014, wasting among children under five was 15.4% in Sindh, whereas
the prevalence of wasting in Umerkot was 22% in children under five. As of the most recent
SMART14 survey conducted by Concern Worldwide in June 2017, GAM was reported as 28.7%
in District Umerkot. The prevalence of acute malnutrition is higher in boys comparatively in
girls. Table 6 and Figure 5 show the prevalence of acute malnutrition in children by gender
and age.

13
WHO (2000). The Management of Nutrition in Major Emergencies.
14 Nutritionand Mortality Survey conducted by Concern Worldwide-June-2017 in Taluka Umerkot of District Umerkot

Page 21 of 43
Table 6: Prevalance of Acute Malnutrition based on Weight-for-Height Z-Score and Sex

Indicators All (n = 470) Boys (n = 250) Girls (n = 220)

Prevalence of global (115) 24.5 % (67) 26.8 % (48) 21.8 %
malnutrition (20.5 - 28.9 95% (20.8 - 33.7 95% (16.2 - 28.8 95%
(<-2 z-score and/or oedema) C.I.) C.I.) C.I.)
Prevalence of moderate (81) 17.2 % (46) 18.4 % (35) 15.9 %
malnutrition (<-2 z-score and > (13.9 - 21.2 95% (13.0 - 25.4 95% (11.5 - 21.6 95%
=-3 z-score, no oedema) C.I.) C.I.) C.I.)
Prevalence of severe (34) 7.2 % (21) 8.4 % (13) 5.9 %
malnutrition (5.1 - 10.3 95% (5.5 - 12.6 95% (3.0 - 11.1 95%
(<-3 z-score and/or oedema) C.I.) C.I.) C.I.)

Figure 5: Prevalence of Acute Malnutrition by Age based on WHZ-Score

90 82.2 84.2
78.9
80
70.5
70 67

60

50

40

30 21.7 21
13.2 15
20 13.2
11.3 8.6 7.9 2.8
10 2.6
0
06-17. 18-29 30-41 42-53 54-59

Severe wasting Moderate wasting Normal

Page 22 of 43
Figure 6: WHZ-Score Distribution

Figures 7: Cumulative Distribution of WHZ (overall and gender)

Prevalence of Acute Malnutrition Based on MUAC Cut-Off point

The prevalence of GAM based on MUAC was 14.0 % (95% CI 11.1 - 17.6). Severe and moderate
acute malnutrition were 3.4% (95% CI 2.1 - 5.4 and 10.6% (95% CI 8.3 - 13.6), respectively.
Based on MUAC the prevalence of acute malnutrition is higher in girls as compared to boys
(Table 7). While based on age distribution, the prevalence of severe acute malnutrition is
higher in children aged 06-17 months as shown in Table 8.

Page 23 of 43
Table 7: Prevalence of GAM based on MUAC and Gender

All Boys Girls

Indicators
(n = 470) (n = 250) (n = 220)
Prevalence of global malnutrition (< (66) 14.0 % (25) 10.0 % (41) 18.6 %
125 mm and/or oedema) (11.1 - 17.6 (6.3 - 15.4 (14.0 - 24.3
95% C.I.) 95% C.I.) 95% C.I.)
Prevalence of moderate (50) 10.6 % (19) 7.6 % (4.5 (31) 14.1 %
malnutrition (< 125 mm and >= 115 (8.3 - 13.6 95% - 12.5 95% (10.3 - 19.0
mm, no oedema) C.I.) C.I.) 95% C.I.)
Prevalence of severe malnutrition (<
(16) 3.4 % (2.1 (6) 2.4 % (1.1 - (10) 4.5 % (2.2
115 mm and/or oedema)
- 5.4 95% C.I.) 5.1 95% C.I.) - 9.2 95% C.I.)

Table 8: Prevalence of Acute Malnutrition by Age based on MUAC:

Moderate wasting
Severe wasting Normal
Age Total (>= 115 mm and
(< 115 mm) (> = 125 mm)
(months) (N) < 125 mm)
No. % No. % No. %
06-17 106 10 9.4 30 28.3 66 62.3
18-29 105 3 2.9 14 13.3 88 83.8
30-41 114 2 1.8 5 4.4 107 93.9
42-53 107 0 0 1 0.9 106 99.1
54-59 38 1 2.6 0 0 37 97.4
Total 470 16 3.4 50 10.6 404 86

Figures 8: Cumulative Distribution (overall and gender) based on MUAC

Page 24 of 43
Prevalence of Stunting based on Height for Age Z- Score and by Gender
The prevalence of stunting was found to be 54% (95% CI 49.1 - 58.9), which means that more
than half of the children under five are below their average heights. This is above the WHO
critical threshold level (≥ 40%). The prevalence of stunting in boys was higher (55.2%; 95% CI
48.4 - 61.8) as compared to girls (52.7 %; 95% CI 46.6 - 58.7 95%) (see Table 9). According to
the Sindh MICS 2014, the prevalance of stunting was 66.2% in children under five. The SMART
Survey conducted by Concern Worldwide in June 2017 found a prevalence of stunting of
47.1%, which was also above the critical threshold . In our survey, the prevalance of severe
stunting in children 18-29 months age group was foudn to be the highest, indicating that
potentially poor care practices may have led to stunting in early childhood as shown in Table
9.
Table 9: Prevalence of stunting based on height-for-age z-scores and by Gender

All Boys Girls

Index Indicators
(n = 470) (n = 250) (n = 220)
(254) 54.0 % (138) 55.2 % (116) 52.7 %
Prevalence of stunting (<-2
(49.1 - 58.9 (48.4 - 61.8 (46.6 - 58.7
z-score)
95% C.I.) 95% C.I.) 95% C.I.)
Prevalence of moderate (110) 23.4 % (56) 22.4 % (54) 24.5 %
WHO
stunting (<-2 z-score and >=- (19.3 - 28.0 (18.5 - 26.9 (18.7 - 31.6
2006
3 z-score) 95% C.I.) 95% C.I.) 95% C.I.)
(144) 30.6 % (82) 32.8 % (62) 28.2 %
Prevalence of severe
(25.5 - 36.3 (25.6 - 40.9 (23.4 - 33.5
stunting (<-3 z-score)
95% C.I.) 95% C.I.) 95% C.I.)

Table 10: Prevalence of stunting by age based on height-for-age z-scores

Severe stunting Moderate stunting Normal

Age Months Total (<-3 z-score) (>= -3 and <-2 z-score) (> = -2 z score)
No. % No. % No. %
06-17. 106 27 25.5 19 17.9 60 56.6
18-29 105 38 36.2 27 25.7 40 38.1
30-41 114 38 33.3 27 23.7 49 43
42-53 107 30 28 30 28 47 43.9
54-59 38 11 28.9 7 18.4 20 52.6
Total 470 144 30.6 110 23.4 216 46

Page 25 of 43
Figures 9: HAZ-Score Distribution

Figures 10: Cumulative Distribution HAZ (Overall and gender)

Prevalence of underweight based on weight-for-age z-scores by sex

Table 11 describes the prevalence of underweight based on weight-for-age z-scores by
gender. The prevalence of global chronic malnutrition/underweight was 55.5 % (95% CI 49.7
- 61.2) and 21.7 % (95% CI 17.6 - 26.4 ). According to the MICS 2014, the prevalence of
underweight was 63.5% in children under five. Similarly, the SMART survey conducted in June
2017 by Concern Worldwide reported a 52.5% prevalence of underweight. There was no
significance difference found between the prevalence of underweight in boys and girls. Table
12 elaborates the prevalence of underweight based on different age groups, indicating a
29.5% prevalence of severe underweight in children 18-29 age group.

Page 26 of 43
Table 11: Prevalence of Underweight based on Weight-for-Age Z-Score and by Gender
All Boys Girls
Index Indicators
(n = 470) (n = 250) (n = 220)
Prevalence of (261) 55.5 % (140) 56.0 % (121) 55.0 %
underweight (49.7 - 61.2 95% (48.7 - 63.1 95% (47.3 - 62.5 95%
(<-2 z-score) C.I.) C.I.) C.I.)
Prevalence of
moderate (159) 33.8 % (84) 33.6 % (75) 34.1 %
WHO
underweight (29.1 - 38.9 95% (27.8 - 40.0 95% (27.5 - 41.3 95%
2006
(<-2 z-score and >=-3 C.I.) C.I.) C.I.)
z-score)
Prevalence of severe (102) 21.7 % (56) 22.4 % (46) 20.9 %
underweight (17.6 - 26.4 95% (16.5 - 29.7 95% (16.2 - 26.6 95%
(<-3 z-score) C.I.) C.I.) C.I.)

Table 12: Prevalence of Underweight by Age based on Weight-for-Age Z-Score

Severe underweight Moderate underweight Normal (> = -2
Age Total
(<-3 z-score) (>= -3 and <-2 z-score) z score)
Months (No.)
No. % No. % No. %
06-17. 106 19 17.9 39 36.8 48 45.3
18-29 105 31 29.5 33 31.4 41 39
30-41 114 26 22.8 41 36 47 41.2
42-53 107 17 15.9 36 33.6 54 50.5
54-59 38 9 23.7 10 26.3 19 50
Total 470 102 21.7 159 33.8 209 44.5

Page 27 of 43
Figure 11: WAZ-Score Distribution

Figure 12: Cumulative Distribution of WAZ (Overall and Gender)

Historical Trend of Malnutrition

Figure 13 elaborates the historical trend of malnutrition in the district based on weight-for-
height, height-for-age and weight-for-age in different surveys.

Page 28 of 43
Figure: 13 Historical Trend of Malnutrition in District Umerkot

Histroical Trend of Malnutrition

70 66.2
63.6
60 53.5 54 55.5
52 52.5
50 47.1

40
28.7 28.8
30 22.9 24.5
20

10

0
MICS 2014 (Govt.) SMART 2016 (Concern SMART 2017 (Concern SMART 2018
Worldwide) Worldwide) (WFP)

WHZ HAZ WAZ Linear (WHZ) Linear (HAZ) Linear (WAZ)

Maternal Nutritional Status

The prevalence of acute malnutrition in PLW was based on MUAC measurements (less than
21 cm) from a total of 142 PLW. The prevalence was reported as 15% in PLW, from which
29% were registered in the Targeted Supplementary Feeding Programme (TSFP). The
prevalence of iron/folic acid supplementation in PLW was found to be 27% only, which is
low as shown in Table 13.

Table 13: Prevalence of Acute Malnutrition in PLW

Taking iron/folic acid Registered in TSFP
Indicator PLW (n= 142) tables (n=38) (n=21)

Prevalence of acute
malnutrition 15% 27% 29%
(MUAC < 21 cm)

Nutrition Programme Coverage

The nutrition programme coverage (OTP and TSFP) for children age 06-59 months and PLW
was calculated based on the total cases of SAM and MAM identified versus the SAM and MAM
cases enrolled in the programme. The overall programme coverage for children 06-59 months
was 11% (OTP: 6% and TSFP: 12%) while the coverage for MAM PLW was recorded as 5% as
shown in Figure 14.

Page 29 of 43
Figure 14: Programme Covarage (Children OTP& TSFP and TSFP PLW)

TSFP PLW 5%

Overall 11%

MAM TSFP 12%

SAM/OTP 6%

0% 2% 4% 6% 8% 10% 12%

Infant and Young Child Feeding Practices (IYCF) in Children 0-23 months
All the sampled households with children aged 0-23 months were assessed for infant and
young child feeding (IYCF) practices as part of the SMART survey. A total of 189 mothers with
children 0-23months were interviewed during this survey.
A 100% of respondents reported breastfeeding their children, 41% initiated breastfeeding
within one hour of birth, 22% initiated breastfeeding within 2-12 hours, while 34% took longer
than 12 hours to start breastfeeding
their children. Only 3% were unable to Figure: 15 IYCF Practices

recall the time they started

100
81
breastfeeding. Exclusive 80
breastfeeding was reported by 26% of 60
41
mothers, while 35% reported also 40 26 23
20
giving water or other liquid along with
0
breastfeeding in the first six months. Early.I.BF Ex.B. 6 Cont.BF Initiation.CF
Majority of mothers (81%) continued month uptp 1 Year at 6 month

breastfeeding their children up to one

year of age. In terms of complementary feeding practices, 23% of children started receiving
complementary feedings at the age of 6 months, 11% of children received complementary
foods before 6 months of age, while 38% started complementary foods later on as per the

Page 30 of 43
appropriate optimal age. The frequency of complementary foods eaten daily was reported by
mother; 10% of mothers fed their children 1-3 times per day and 69% fed their children more
than 3 times per day.
In terms of awareness sessions conducted related to mother’s milk and child nutrition, 47%
mothers reported that they received an awareness session from lady health workers/NGOs
workers.
Additionally, 69% of households were identified as using iodized salt through a Rapid Test Kit
(RTK).

Minimum Dietary Diversity (MDD)

The minimum dietary diversity (MDD) score is a population-level indicator designed by the
World Health Organization (WHO) to assess dietary diversity among children 6-23 months old.
The MDD is calculated based on the number of WHO recommended food groups consumed
by the child during the last 24 hours. To obtain MDD, a child aged 06-23 months must
consume at least 4 of the WHO recommended food groups. The overall MDD score was found
to be very low (0.1), indicating very poor dietary diversity. Figure 16 describes the overall
MDD and the percentage of children who received less than 4 foods group, at least 4 food
groups and more than 4 food groups.

Figure: 16 Minimum Dietary Diversity for children age 06-23 months

Figure 16: Minimum Dietary Diversity (06-23 month)

92% 5% 3% 0.1

Children who Children who Children who Overall MDD

consumed < 4 consumed 4 food consumed > 4
food groups groups food groups

Household Food Security Circumstance

Household circumstance questionnaire was used to gauge the average household size,
livelihood/income source and household coping strategies to fulfil the basic needs of the
household.

Page 31 of 43
Average Household Size (AHHS)
The average household size of the surveyed households was 6.3 members, with an average
of 1.2 children under five years of age.

Source of income/livelihood

The main source of income was unskilled wage labour (37%), followed by shared cropping
(29%) and skilled wage labour (13%) (Figure 17).

Figure 17: Source of income/livelihood

Farming own land
6%

unskill wage labor

37% Farming share crop
29%

income support
0.2%

livestock
2%

remittances
skill wage labor govt
0.5%
13% shopekeeper 10%
3%

Household Coping Strategy

The household coping strategy was examined to evaluate the household food security
situation and their coping mechanisms. All the surveyed households, were asked whether
they had faced any difficulty in fulfilling the basic needs of the household in the past month.
Among the households, 45% reported that they had faced problems in fulfilling their basic
household needs in the last month. With further probing, 40% of the households reported
that they faced problems 1-2 days per week, 34% experienced problems 1-2 times a month,
32% faced more than 3 days per week, while only 16% had hardly ever faced problems
fulfilling their basic household needs.

Page 32 of 43
Some of the coping strategies used were skipping meals (4%), reliance on less preferred and
expensive foods (25%), restricted consumption by adults in order for smaller children to have
something to eat (0.4%), consumption of seed stocks held for the next season (4%), sought
out alternate or additional jobs (14%) and loan of food items from other households (5%).
Multiple coping strategies were adopted by households; 33% of the households adopted two
coping strategies and 15% adopted more than 2 coping strategies to fulfil their basic
household needs.

Household Dietary Diversity (HDDS)

The Household Dietary Diversity Score (HDDS) is a population level indicator of household
food access. The HDDS is based on the number of different food groups consumed by the
head of household or any other household member based on a 24-hour recall. The overall
HDDS was 4.7 as shown in figure 15. This means that on average, each of the assessed
household consumed only 4.7 out of the 12 food groups at the household level, indicating
poor access to diverse foods. In terms of the food groups consumed by households, cereals
were reported to be the most consumed, followed by vegetables, milk products, roots and
tubers, pulses and legumes. A proportional break-up of the 4.7 HDD score is presented in
Figure 18.
Figure 18: Household Dietary Diversity Score (HDDS)

Figure 17: HHs Dietary Diversity Score (HDDS)

23% 27% 50% 4.7

HHs conusmed < HHs conusmed 4 HHs conusmed > Overall HDDS
4 food groups food groups 4 food groups

Child
Morbidity
Information on child morbidity was collected through a two-week parental or caregiver recall
period, the parents or caregivers were asked to recall whether the child had any illness in the

Page 33 of 43
last two weeks and if so, what type of illness. This information was gathered from all children
aged 06-59 months whose anthropometric measurements were collected; out of these
children, 33% (156) reported experiencing an illness in the last two weeks. In terms of the
type of illness, 16% (25) reported diarrhoea, 7% (11) reported acute respiratory infection
(ARI), 78% (78) reported fever and 27% (42) reported a combination of all three diseases (i.e.
diarrhoea, ARI and fever). Further probing on care seeking behaviours revealed that 13 (8%)
sought no treatment, 16% (25) availed the services of general practitioner, 63% (98) visited
government hospitals and 12% (19) sought out other services, such as home based treatment
(Figures 19 and 20).
Figure 19 and 20: Trends of Child morbidity and Health Services Seeking Behaviours

78 Health services Seeking Behaviours

80
70
100 98
60 42
50
25
40 13 25
11 19
50
30 1
20
10 0
0
No treatment General Pract Hospital
Diarrhea ARI Fever All Traditional Other

Mortality
The results of the survey identified the crude mortality rate (CMR) as 0.08/10,000 per day and
an under-five mortality rate (U5MR) as 0.44 /10,000 per day. The CMR and U5MR are below
the WHO15 emergency threshold. The cause of death was often linked with distance from or
lack of access to treatment centres. However, the mortality rates could be correlated with
comparatively less harsh seasonality factors during the survey period.

15 Crude mortality rate (CMR) is 1 per 10 000 per day and 2 per 10 000 per day for under-five mortality rate (U5MR).

Page 34 of 43
Table: 14 CMR &U5MR
Indicators Description Results
Crude Mortality Rate Total deaths (95 days) / 10,000
0.08 (0.01-0.61)
(CMR) population / day
Under-five Mortality Under-five deaths (95 days) / 10,000
0.44 (0.06-3.16)
Rate (U5MR) children under five / day
Male 0.16 (0.02-1.20)
Female 0.00 (0.00-0.00)

Vaccination and Vitamin-A Coverage

The vaccination coverage rate, including BCG and measles, was assessed for children 06-59
months by observing the presence of a BCG scar on the right upper arm, and the measles
vaccination status on the vaccination card or confirmation via mother’s recall. Vitamin A
coverage was also ascertained by mother’s recall. A total of 78% of children had a BCG scar,
34% had received a measles vaccination confirmed by a vaccination card, 58% had received a
measles vaccination confirmed through mother’s recall and 91% had received vitamin A
supplementation confirmed through mother’s recall (Table 15).

Table 15: Vaccination (BCG, Measles) and Vitamin-A coverage

BCG Measles Measles by Vitamin A
by scar by card mothers recall by recall

78% 34% 58% 91%

Water, Sanitation and Hygiene (WASH)

Safe drinking water is necessary for good health. Lack of safe drinking water can significantly
contribute to the spread of water borne diseases like cholera and typhoid. Drinking water can
be tainted with chemical and physical contaminants, which have harmful effects on human
health.
Households Water Source
Hand pump, unprotected spring, piped water and public taps are the main sources of water
in district Umerkot. The community relies on these water sources and uses them for cooking
and personal hygiene at household level. Majority of the households relied on hand pumps
(48%) as their main source of water, followed by unprotected springs (19%) and piped water
(15%). Figure 21 provides a detailed description of the main source of water and utilization at
household level.

Page 35 of 43
Figure: 21 water sources for drinking and personal hygiene

Piped water – piped into dwelling public tap stand

Hand pump Tube well / turbine
Covered (protected) well Uncovered (unprotected) well
Unprotected spring

15%
19%

10%
3% 1%

4%

48%

Water accessibility
Majority of the households (58%) can access a water source within 30 minutes walking
distance from their dwellings. Another 14% can access a water source by walking 30-60
minutes and 7% can access a source by walking 1-2 hours. Adult women (58%) had the main
responsibility of collecting water for the household. Around 11% of children and 4% of adult
men collected water for the household. Only 27% of the households confirmed that all family
members (children, adult men and women) were responsible for collecting water for the
household.

Use of Water
According to 53% of respondents, the water they used is safe and did not require any
treatment prior to drinking. However, 31% filtered their water with cloth, 12% let debris
settle, 2% boiled their water and 2% used local sand filters.

Hand Washing
Handwashing with water and soap is the most cost-effective health intervention to reduce
major water related diseases in children under five, especially diarrhoea. It is most effective
when practiced after visiting a toilet or cleaning a child’s faeces, before eating or handling
food and, before feeding a child. The survey result revealed that 50% of the participants
washed their hands before preparing, serving, eating, feeding children and after attending

Page 36 of 43
the toilet, while 49% reported that they washed their hands after cleaning the child’s bottom
along with the above-mentioned activities. Furthermore, it was noticed that 76% of the
households used detergent soap, based on observation.

Availability of latrine facility

An improved sanitation facility is defined as one that hygienically separates human excreta
from human contact. Improved sanitation facilities for excreta disposal include flush or pour
flush to a piped sewer system, septic tank, or pit latrine; ventilated improved pit latrine, pit
latrine with slab, and use of a composting toilet. Availability of a protected latrine impacts
domestic and personal hygiene and plays a role in prevention of diarrhoea. The survey results
indicated that 23% of the household have a flush latrine, 14% have a pit latrine and 62% have
no latrine facility and practice open defection.

Conclusion
The SMART assessment broadly explored and analyzed the nutrition situation of children and
mothers in district Umerkot. The findings correspond with the apprehension of the Sindh
government and further validates the September 2018 notification16 declaring Umerkot as
part of the calamity-affected areas.

The study results depict alarmingly high levels of both acute and chronic malnutrition across
all surveyed union councils of the district Umerkot, affecting both the urban and rural
population alike17. The prevalence of acute malnutrition based on weight-for-height was 24.5
% (SAM 7.2 % & MAM 17.2 %). While, the prevalence of stunting was estimated at 54%,
exceeding the WHO critical threshold level (≥ 40%). There were 15% of PLW found to be
malnourished. Due to scattered population settlements, the existing CMAM nutrition
programme coverage is patchy, with an 11% overall coverage.

The study findings also highlighted serious gaps in IYCF practices with only 26% of mothers
reported to have exclusively breastfed and only 23% of children (6-23months) reported to
have initiated complementary feeding at the age of 6 months. The poor IYCF indicators
correspond with the lack of awareness on part of the mothers in the surveyed communities.
Only 47% mothers could acknowledge at least one-time participation in an awareness session

16
https://tribune.com.pk/story/1796438/1-sindh-govt-declares-drought-six-districts/
17
Urban: 23.9% GAM, Rural: 24.5% GAM

Page 37 of 43
on IYCF from lady health workers or NGOs workers in the area. The overall HDDS was 4.7,
while the overall MDD score of 08 for children 6-23 months of age indicates very poor dietary
diversity, a potential reason for the macro- and micro-nutrients deficiencies.

The study findings indicated an estimated prevalence of 16% in diarrheal diseases and 7% of
ARI in children aged 6-59 months of age. The EPI coverage was reported at 78% for BCG, 34%
for measles and 91% for vitamin A supplementation. The crude mortality rate and under five
mortality rate were found to be below the WHO18 emergency threshold, which may be due
to timing of the assessment during a comparatively less harsher season of the year.

There is limited awareness on the concept and importance of safe drinking water as only 02%
of households practiced boiling of water for cleaning purpose. A total of 53% of the
respondents perceived their water source to be safe for drinking, while 31% used cloth to
filter water before drinking. Nearly half of the interviewed households do not practice hand-
wash before meals and after attending latrines, although soap/detergent availability was
observed in 76% of the households. Open defection poses a key risk for water contamination
and diarrheal disease spread, particularly in the western region of Umerkot due to the high-
water table and open sewage systems.

The reported low HDDS reflects poor household level food security and compromised socio-
economic status of the population in Umerkot, indicating higher risks in case of any prevailing
shocks in the form of drought. Furthermore, the limited landowner ship (only 6%) and reliance
on 37% unskilled waged workforce emphasizes the need to scale-up the immediate
nutritional support to the vulnerable groups (<5years of age and PLW) and invest in medium
and long term food security initiatives to address the nutrition needs of population.

Recommendations:
• Scale-up of emergency CMAM based nutrition interventions to a maximum level with
increased access and coverage to reach the inaccessible areas. The critical situation of
acute and chronic malnutrition necessitates for early identification of the acutely
malnourished children, preferably before they become severely malnourished.

18 Crude mortality rate (CMR) is 1 per 10 000 per day and 2 per 10 000 per day for under-five mortality rate (U5MR).

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• Gradually, compliment and later substitute, the CMAM interventions with more cost-
effective food based preventive nutrition specific initiatives focusing on 1000 days’
window i.e. conception till child is 24 months of age.
• Advocate for multi-sectoral medium and long-term nutrition specific and sensitive
interventions preferably through Government’s Annual Development Plans (PC-1) as
some of the provinces have already initiated multi-sectoral stunting prevention
initiatives ensuring access to children and PLW at an early phase, before they become
malnourished (e.g. KP-SPRING PC-1).
• Introduce diverse awareness initiatives on preventive nutritional care through print
and electronic media, advocating for wise utilization of household income on
nutritional food commodities and discouraging the use of junk foods (including
ghutka) by children and women. (Caution: Separate contextual content needs to be
developed for Hindus and Muslims communities, keeping view the food priorities)
• Capacitate the Department of Health (Nutrition Support Programme) for improving
LHWs coverage with a focus on improving awareness on IYCF practices, preferably
through Positive Deviance (PD) approach, as this alone could significantly contribute
to improving mother’s knowledge, attitude and practices for improving their new-
born’s nutritional status.
• Political awareness and accountability for motivating the municipal committee’s role
in improving the water and sanitation situation, particularly in discouraging open
defecation, and improving safe disposal of wastes and water quality. The issue of
salinity is beyond the scope of this study and may require more expert inputs and a
separate study to offer cost-effective practical solutions.

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 Annexure: I Plausibility Check

Flagged data Overall sex Overall age Digit pref. Digit pref. Digit pref. Standard Skewness Kurtosis Poisson Overall
CRITERIA (% of in-range ratio distribution score score score deviation WHZ WHZ distribution score WHZ
subjects) Weight Height MUAC WHZ WHZ

Score 0 (2.1 %) 0 (p=0.166) 0 (p=0.647) 0 (4) 0 (7) 0 (6) 0 (1.01) 1 (-0.29) 0 (0.12) 3 (p=0.006) 4%

Interpretation Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Acceptable Excellent
 Annexure: II List of Surved Clusters

Date
Taluka Union Council Deh Geographical unit Cluster Team Day of visit Team Leader
of visit
Umerkot Muncipal Committee Umerkot Umerkot Circle-III 1 A 19-Nov Monday Abdual Qayoom
Umerkot Muncipal Committee Umerkot Vehro Thar Sajan Babar 2 B 18-Nov Sunday Roshan Faqeer
Umerkot Town Committee Dhoronaro Sahib Tar Dhoronaro Shehar 3 C 18-Nov Sunday Muhammad Fayaz
Umerkot Debho Debo Eisa Halepoto 4 D 18-Nov Sunday Mazhar Hussain
Umerkot Faqeer Abdullah Sabri Thar Sabri Kumbhar 5 E 18-Nov Sunday Muhammad Azeem
Umerkot Gapno Gapno Umer Din Arain 6 F 18-Nov Sunday Muhammad Rawal
Umerkot Haji Mian Shah Kharoro Jagir Asserlo Gomand Bajeer 7 A 18-Nov Sunday Abdual Qayoom
Umerkot Kaplore Kacholi Mithrio Kharo 8 B 22-Nov Thursday Roshan Faqeer
Umerkot Khan Sb Atta Mohd Palli Khiral Sahiban-jo- Kot 9 C 19-Nov Monday Muhammad Fayaz
Umerkot Khejrari Sabri Pat Baboo Nohri 10 D 19-Nov Monday Mazhar Hussain
Umerkot Koonjheli Sonhin Sharif Samejo 11 E 19-Nov Monday Muhammad Azeem
Umerkot Mir Wali Mohammad Talpur Dugoo Mohammad Bux Solangi 12 F 19-Nov Monday Muhammad Rawal
Umerkot Sabho Nohiyon Nohiyon Abra 13 A 20-Nov Tuesday Abdual Qayoom
Umerkot Shekhro Shekhro Shekhro 14 B 19-Nov Monday Roshan Faqeer
Umerkot Soofi Dhorosarin Village Mubarak Khan 15 C 20-Nov Tuesday Muhammad Fayaz
Umerkot Walidad Palli S.Khejrari Goth Murad Ali Palli 16 D 20-Nov Tuesday Mazhar Hussain
Kunri Town Committee Kunri Partially of Deh
20-Nov Tuesday
Chajro and Goraho Kunri Town 17 E Muhammad Azeem
Kunri Kunri Memon Kunri Jam Memon Otaq 18 F 20-Nov Tuesday Muhammad Rawal
Kunri Bustan Khamnoon Rehmatullah Gil 19 A 22-Nov Thursday Abdual Qayoom
Kunri Chajro Goraho Noor Mohammad/Halepato 20 B 20-Nov Tuesday Roshan Faqeer
Kunri Nabisar Nabisar Pat Nabisar Thar village 21 C 21-Nov Wednesday Muhammad Fayaz
Kunri Nawababad @Manjhakar Seerkhi Haji Ibrahim 22 D 21-Nov Wednesday Mazhar Hussain
Kunri Sher Khan Chandio Saeedki Mohammad Ismail Jhanjhi 23 E 21-Nov Wednesday Muhammad Azeem
Kunri Talhi Talhi Talhi Town 24 F 22-Nov Thursday Muhammad Rawal
Samaro Gulzar-e-Khalil Pir Sarhandi Khani Noor Mohammad Birohi 25 A 23-Nov Friday Roshan Faqeer
Samaro Padhrio Soonthi Otaque Yousif Khaskheli 26 B 21-Nov Wednesday Roshan Faqeer
Samaro Rais Noor Khan Dhonkai @ Timo Kharo Darya khan Dhounkai
23-Nov Friday
Cheema Stop 27 C Muhammad Fayaz
Samaro Samaro Khararo East (Samaro Town) 28 D 22-Nov Thursday Mazhar Hussain
Samaro Samaro Old Layari Sulleman Khaskheli 29 E 23-Nov Friday Muhammad Azeem
Samaro Satriyoon 16-Hiral Noor Ali Shah 30 F 21-Nov Wednesday Muhammad Rawal
Samaro Town Committee Samaro Araro Mir Abdullah 31 A 21-Nov Wednesday Abdual Qayoom
Pithoro Town Committee Shadi Palli Gurki Kaloo Khan 32 B 23-Nov Friday Abdual Qayoom
Pithoro Chachhro @ Syed Ghulam Pithoro
22-Nov Thursday
Hyder Shah T.C. Pithoro 33 C Muhammad Fayaz
Pithoro Ghulam Nabi Shah Ghulam Nabi Shah Ghulam Nabi Shah 34 D 23-Nov Friday Mazhar Hussain
Pithoro Haji Peer Shah Shadi Palli Sadique Abad 35 E 22-Nov Thursday Muhammad Azeem
Pithoro Shah Mardan Shah Hiral-1 Saddardin Arisar 36 F 23-Nov Friday Muhammad Rawal
Umerkot Muncipal Committee Umerkot Umerkot Circle-1 RC
Umerkot Larh Haji Allah Bachayo Bhambhro
Town Committee Chhore Otaque RC
Kunri Dhambharlo Malook Shah Sanvalo Chandio RC
Kunri Town Committee Nabisar Rahmore Nabisar Road RC

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